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Pain in RA Remission — SCE Rheumatology MCQ

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ModerateRheumatoid ArthritisPain in RA RemissionSCE Rheumatology

A 55-year-old man with established rheumatoid arthritis has sustained DAS28-CRP remission (DAS28-CRP 1.9). He reports diffuse musculoskeletal pain, fatigue and unrefreshing sleep. There are no swollen joints, his CRP is normal, and ultrasound of the symptomatic joints shows no evidence of active synovitis. Examination demonstrates widespread pressure hyperalgesia at both articular and non-articular sites. Which pain mechanism is most likely to be dominant?

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Correct answer: D — Nociplastic pain associated with central sensitisation

The dominant mechanism is nociplastic pain associated with central sensitisation. Widespread pain, pressure hyperalgesia at non-articular as well as articular sites, fatigue and unrefreshing sleep are characteristic discriminators. The absence of swollen joints, raised CRP or ultrasound synovitis makes active inflammatory nociception and persistent subclinical synovitis unlikely. Secondary osteoarthritis can cause pain despite RA remission, but it usually produces focal, mechanically provoked symptoms rather than generalised hyperalgesia. Peripheral nociception alone would also not explain this widespread sensitised phenotype. Persistent pain does not invalidate inflammatory remission, and escalation of DMARD therapy is inappropriate without evidence of active inflammation; assessment should instead address centrally mediated pain and relevant sleep, mood and functional contributors.

Reference: Rutter-Locher Z, Denk F, Taams LS, Kirkham BW, Bannister K. Towards an individualised approach to pain management in inflammatory arthritis. Therapeutic Advances in Musculoskeletal Disease. 2026. https://pubmed.ncbi.nlm.nih.gov/37634676/